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Pre-Existing Conditions and Work-Related Injuries

When a person sustains an injury on the job, they deserve to be compensated for their medical expenses, through a process often called “workers’ comp.”

Many Americans across the country will depend on workers’ comp at some point in their lives. Those of us here in Pennsylvania are no exception. Consider these statistics from the Pennsylvania Workers’ Compensation & Workplace Safety 2015 Annual Report. In 2015, there were 166,102 workers’ comps qualified injuries and illnesses across the Commonwealth. Sprains and strains were the most common, accounting for 63,858 claims. Contusions, bruises and other crushing injuries were the second most common, at 30,090 claims. Upper extremities, such as hands and arms, were the most common sites of injuries, at 62,155 claims, with lower extremities accounting for the second most at 35,797

These statistics only account for the workers’ comp claims filed in Pennsylvania. Needless to say, for many people working in a wide range of industries, workers’ comp is essential for helping hard working individuals get the medical care they need.

However, workers’ comp claims, by definition, involve antagonistic relationships between the insurance companies of both employers and employees. Because compensation comes from a claim against the employer’s insurance, the employer is incentivized to dispute this claim if they believe that the injury could have been caused by something other than work. If there is a dispute, attorneys become involved, with each party attempting to prove that culpability for the injury should or should not fall on the employer.

This question becomes even more complicated when preexisting conditions are involved. Just because someone has a preexisting condition does not mean they are disqualified from worker’s comp. However, the degree to which the injury was caused by a work environment needs to be determined.

That’s why we’ve put together this guide on how to determine if a work-related injury was preexisting. Helping to make sense of complicated medical histories impartially is our specialty. So if you’re concerned about the relationship between a preexisting condition and a workers’ comp injury, join us as we try to give you an unbiased look at the question.

 

 

Are the Conditions Related?

The first step is to determine if the conditions are in fact related.

Consider this hypothetical. Keep in mind, in such hypothetical situations, conditions are discussed in the broadest terms, and an expert will be required to determine whether a preexisting condition is related or not.

A worker injures her back while performing a heavy lift. However, she had suffered a severe knee injury in a car accident years before. Does this pre-existing condition relate to her new injury?

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If the injury was repaired properly and the worker had been diligent in compensating for the injury, then they are likely unrelated. The vast majority of workers will have suffered some injury in the past.

However, let’s say she injured her back because as she was lifting, her knee gave out, causing her to lose her balance.

In this case, the conditions are related. However, this does not mean that she is not entitled to workers’ comp. It just means that the case becomes more complicated. Doctors, lawyers and insurance adjusters are going to have to look at the data and determine if the employer is financially responsible for the back injury.

What Caused the Pre-Existing Condition?

One also needs to determine from where the preexisting condition arose. Was this an injury caused by a college sports career or was the preexisting condition similarly work related.

Let’s return to the above hypothetical. Instead of having a preexisting knee injury, let’s assume that years of hard labor had caused the worker to have a number of asymptomatic back problems. This is quite common among manual laborers. Bulging discs or cord compression can develop over the years without causing a person any physical pain. However, a single injury could suddenly cause extreme pain, even if the precipitating event wasn’t that serious.

If the woman had been working for the same employer all those years as her back issues developed, then the workers’ comp claim will likely be simple to settle. Even though the precipitating event was exacerbated by a preexisting condition, that condition can still be attributed to work.

However, what if the employee was new to this particular job, and the preexisting condition originated at another job. The employer and their insurance company may attempt to claim that the injury was caused by the previous job, not the current one.

In this case, a doctor will have to determine if the work accident caused a mechanical change that led to the injury.

Think of it like this. You have a half-inflated balloon, and you poke it with a pin. There’s a good chance that it won’t pop. Now, you have a fully and properly-inflated balloon, and you poke it. It will likely pop, and if it does, you would say that the pin is responsible for popping it, as, under normal conditions, a balloon is designed not to pop. However, let’s say that you have an overly-inflated balloon. A lot of things could pop an over-inflated balloon, including a number of things that wouldn’t pop a balloon under normal conditions. However, even if the balloon is floating aimlessly and happens to land on your pin unintentionally, the pin is still ultimately responsible for its popping.

As long as the doctor can say that the accident acted like that pin, serving as the precipitating event causing the injury, an injured worker is entitled to workers’ comp.

Does the Pre-Existing Condition and the New Injury Overlap?

At this point, things start to get complicated.

Let’s say a man is working in a machine shop and gets his hand caught in a machine. In the process, he causes permanent damage to his hand, limiting his future employability.

However, in a previous job, he had already injured that hand. While he was still capable of performing his new job, his hand already had limited functionality.

To what extent is the current job responsible for his future limitations and to what extent is the previous job responsible?

This will require a thorough examination by a doctor. A doctor will examine the new injury while also looking at past scarring. They will also compare the new injury with charts made by the doctor who treated the previous injury.

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The same is true if the new injury is exacerbating a preexisting condition. In this case, a professional will determine the degree to which the new injury is making the condition worse.

Were There Prior Rewards Related to the Injury?

There are a couple of considerations to keep in mind related to a preexisting condition that came with a corresponding workers’ comp award.

First of all, all statements related to that previous award become relevant to the new workers’ comp case. Because previous statements are considered to be part of the record, they can be used as evidence either for the employee or employer. Similarly, doctors may call upon this as evidence for determining the degree to which the new condition is a consequence of the new injury.

But prior rewards are not a reason to disqualify a new claim outright. Workers’ comp awards are responses to a person’s ability to work after a precipitating event. If a person had recovered from a prior injury but a new injury re-aggravated that problem, that person is once again entitled to compensation.

However, workers’ comp lawyers working with a medical professional may determine that the original issue was never properly corrected, or otherwise still ultimately responsible for the worker’s inability to work, at which point the claim may be made against the old employer’s insurance. This determination requires the judgment of professionals well-versed in the issues of work injury diagnosis and law.

Are Lawyers Required?

While we are first and foremost medical professionals in the field of injury and workers’ comp medicine, it should be noted that lawyers are essential for workers’ comp claims. Workers’ comp awards and the determination of their extent are based on an adversarial system in which two law professionals argue against each other advocating for their clients — either the employer or the employee. The panel empowered to decide these cases will then look at the facts presented and determine whether to award the claim or not.

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Neither employers nor injured employees are likely to be well-versed in this complicated set of laws and regulations. That’s why lawyers are so important to the process. They represent their parties and are charged with making the most compelling case from the perspective of their client. So while lawyers may not be required by law, the system is designed for lawyers, and as such, they should always be contacted in the event of a workers’ comp claim.

Can Any Doctor Be Consulted?

Most injured employees turn first to their family doctor to determine the extent of the injury, whether the injury is permanent or temporary and what steps need to be taken to recover.

If the injury is severe enough, of course, the emergency room should be an employee’s first stop, as they will be able to treat trauma and stabilize the injury.

This is a good first step and in the case of an emergency, caring for a person’s health should be the primary concern.

However, some medical professionals are better prepared to deal with issues of workers’ comp determinations than others.

Remember, a family doctor is an advocate for the employee’s health — which is a good thing. Everyone deserves to have someone who will work hard to advocate for their well-being.

However, that also means that the family doctor isn’t completely impartial. They will naturally want to make sure that their patient is cared for. This is not to say that they are unprofessional, just that they are going to be partial to the patient.

That’s where an independent medical examination (IME) comes in. IMEs are by definition neither working for the employee nor the employer. They make impartial judgments based on the facts, and those facts are then made equally available to both the plaintiff and defense.

This offers a number of benefits to both parties. Without an IME, an employee’s doctor and the employer’s lawyers may not see eye to eye and therefore dispute the findings. This drags the process out. If the injured employee is entitled to workers’ comp, that means the employee has to wait to receive the funds that they are entitled to. If the employee is not entitled, then the employee will have wasted time waiting for a ruling when they could have been exploring other available options.

Additionally, the investigative process invariably costs money. By dragging the process out, both parties will likely lose money. While one party may be able to recoup those funds through further compensation claims, both parties would do well to avoid spending it in the first place.

However, more than any other quality, an IME understands how the workers’ comp process works. They know what to look for when examining an injury, and can accurately separate preexisting conditions from current injuries. They have experience measuring the various facts and making a determination that is fair to both the injured and employer.

Not only do they know what to look for, but they also know how to present that information to legal professionals and the body that will determine the validity of a workers’ comp claim. This information needs to be presented in highly prescribed forms, and the requirements can be overwhelming to the uninitiated. Whether the claim requires a narrative form, a particular addendum or a video and oral deposition, an IME has the experience necessary to complete these extremely important tasks accurately and promptly.

Are There IMEs in Central Pennsylvania?

In short, yes!

Here at the IME Care Center, we examine and process workers’ comp cases, including those that involve preexisting conditions, for patients and companies in Harrisburg, Camp Hill, Carlisle and Sunbury, PA. We offer professional and unbiased examinations and reports performed by board-certified physicians.

Our service is comprehensive, including examinations, depositions, record reviews, functional capacity evaluations, narrative letters, and utilization reviews.

We also offer convenient scheduling, which is essential when going through the complicated workers’ compensation process. Because all parties involved have their busy schedules to balance, having an IME that can flexibly schedule will help prevent frustrating delays in processing.

We also boast quick turnaround times. Because we have so much experience with the specifics of the workers’ comps process, examinations, we can process paperwork quickly and efficiently, all without the worry of mistakes related to carelessness, inexperience or rushing.

Finally, because we are so focused on workers’ compensation and other injuries, we have physicians who specialize in the kinds of categories that are most common within workers comps claims. Whether you need an ophthalmologist, a cardiologist, a psychiatrist, an orthopedic specialist, or an expert in pain management, we have a physician who understands the specifics surrounding the relevant injury issue.

So if you are in need of an IME in Central, PA with experience in workers’ comp cases involving a preexisting condition or if you simply want to familiarize yourself with the process so that you are prepared in the future, contact us today!